f Post graduate mcqs and discussion : ACUTE SUPPURATIVE OTITIS MEDIA

Friday, March 30

ACUTE SUPPURATIVE OTITIS MEDIA

It is an acute inflammation of middle ear by pyogenic organisms. Here, middle ear implies middle ear cleft, i.e. eustachian tube, middle ear, attic, aditus, antrum and mastoid air cells.

AETIOLOGY

It is more common especially in infants and children of lower socioeconomic group. Typically, the disease follows viral infection of upper respiratory tract but soon the pyogenic organisms invade the middle ear.

Fig: ACUTE SUPPURATIVE OTITIS MEDIA

PREDISPOSING FACTORS 

Anything that interferes with normal functioning of eustachian tube predisposes to middle ear infection. It could be:
1. Recurrent attacks of common cold, upper respiratory tract infections and exanthematous fevers like measles, diphtheria or whooping cough.
2. Infections of tonsils and adenoids.
3. Chronic rhinitis and sinusitis.
4. Nasal allergy.
5. Tumours of nasopharynx, packing of nose or nasophar￾ynx for epistaxis.
6. Cleft palate.

PATHOLOGY AND CLINICAL FEATURES

1. Stage of tubal occlusion. 

Oedema and hyperaemia of nasopharyngeal end of eustachian tube blocks the tube leading to absorption of air and negative intratympanic pressure. There is retraction of tympanic membrane with some degree of effusion in the middle ear but fluid may not be clinically appreciable. Symptoms. Deafness and earache are the two symptoms but they are not marked. There is generally no fever. Signs. Tympanic membrane is retracted with handle of malleus assuming a more horizontal position, prominence of lateral process of malleus and loss of light reflex. Tuning fork tests show conductive deafness.

2. Stage of presuppuration. 

If tubal occlusion is prolonged, pyogenic organisms invade tympanic cavity causing hyperaemia of its lining. Inflammatory exudate appears in the middle ear. Tympanic membrane becomes congested. Symptoms. There is marked earache which may disturb sleep and is of throbbing nature. Deafness and tinnitus are also present, but complained only by adults. Usually, child runs high degree of fever and is restless. Signs. To begin with, there is congestion of pars tensa. Leash of blood vessels appear along the handle of malleus and at the periphery of tympanic membrane imparting it a cart-wheel appearance. Later, whole of tympanic membrane including pars flaccida becomes uniformly red. Tuning fork tests will again show conductive type of hear￾ing loss.

3. Stage of suppuration. 

This is marked by formation of pus in the middle ear and to some extent in mastoid air cells. Tympanic membrane starts bulging to the point of rupture. Symptoms. Earache becomes excruciating. Deafness increases, child may run fever of 102–103°F. This may be accompanied by vomiting and even convulsions. Signs. Tympanic membrane appears red and bulging with loss of landmarks. Handle of malleus may be engulfed by the swollen and protruding tympanic membrane and may not be discernible. A yellow spot may be seen on the tym￾panic membrane where rupture is imminent. In preantibi￾otic era, one could see a nipple-like protrusion of tympanic membrane with a yellow spot on its summit. Tenderness may be elicited over the mastoid antrum. X-rays of mastoid will show clouding of air cells because of exudate.

4. Stage of resolution.

The tympanic membrane ruptures with release of pus and subsidence of symptoms. Inflamma￾tory process begins to resolve. If proper treatment is started early or if the infection was mild, resolution may start even without rupture of tympanic membrane. Symptoms. With evacuation of pus, earache is relieved, fever comes down and child feels better. Signs. External auditory canal may contain blood-tinged discharge which later becomes mucopurulent. Usually, a small perforation is seen in anteroinferior quadrant of pars tensa. Hyperaemia of tympanic membrane begins to subside with return to normal colour and landmarks.

5. Stage of complication.

 If virulence of organism is high or resistance of patient poor, resolution may not take place and disease spreads beyond the confines of middle ear. It may lead to acute mastoiditis, subperiosteal abscess, facial paralysis, labyrinthitis, petrositis, extra￾dural abscess, meningitis, brain abscess or lateral sinus thrombophlebitis.


TREATMENT

1. Antibacterial therapy

 It is indicated in all cases with fever and severe earache. As the most common organisms are S. pneumoniae and H. influenzae, the drugs which are effective in acute otitis media are ampicillin (50 mg/kg/day in four divided doses) and amoxicillin (40 mg/ kg/day in three divided doses). Those allergic to these peni￾cillins can be given cefaclor, co-trimoxazole or erythromy￾cin. In cases where β-lactamase-producing H. influenzae or M. catarrhalis are isolated, antibiotics like amoxicillin clavulanate, augmentin, cefuroxime axetil or cefixime may be used. Antibacterial therapy must be continued for a mini￾mum of 10 days, till tympanic membrane regains normal appearance and hearing returns to normal. Early discontin￾uance of therapy with relief of earache and fever, or therapy given in inadequate doses may lead to secretory otitis media and residual hearing loss.

2. Decongestant nasal drops. 

Ephedrine nose drops (1% in adults and 0.5% in children) or oxymetazoline (Nasivion) or xylometazoline (Otrivin) should be used to relieve eustachian tube oedema and promote ventilation of middle ear.

3. Oral nasal decongestants. 

Pseudoephedrine (Sudafed) 30 mg twice daily or a combination of decongestant and anti￾histaminic (Triominic) may achieve the same result without resort to nasal drops which are difficult to administer in children.

4. Analgesics and antipyretics. 

Paracetamol helps to relieve pain and bring down temperature.

5. Ear toilet.

If there is discharge in the ear, it is dry-mopped with sterile cotton buds and a wick moistened with antibiotic may be inserted.

6. Dry local heat helps to relieve pain.

7. Myringotomy. It is incising the drum to evacuate pus and is indicated when (i) drum is bulging and there is acute pain, (ii) there is an incomplete resolution despite antibiot￾ics when drum remains full with persistent conductive deaf￾ness and (iii) there is persistent effusion beyond 12 weeks.